What primarily distinguishes fraud from waste and abuse?

The primary distinction between fraud and waste and abuse lies in intent and knowledge. Fraud typically involves intentional deception or misrepresentation with the purpose of securing an unauthorized benefit or payment. This indicates that the individual engaged in fraudulent activities is aware of their actions and knows that what they are doing is wrong or improper.

On the other hand, waste and abuse may occur without malicious intent. Waste refers to practices that result in unnecessary costs to the healthcare system, often due to inefficient practices or over-utilization of services. Abuse may involve practices that are inconsistent with sound fiscal, business, or medical practices but are not done with fraudulent intent.

By focusing on the intent and knowledge of the individual involved, it becomes clear that fraud represents a more serious infraction due to its willful nature, distinguishing it from the less intentional activities categorized as waste and abuse.